Starshine Registration Form
Please fill out this form for EACH family of Starshine participants.
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Participant name (first, last) *
Participant preferred pronouns *
Participant age *
Parent/Guardian name (first, last) *
Parent/Guardian preferred pronouns *
Parent/Guardian email *
Parent/Guardian phone *
Parent/Guardian physical address *
Parent/Guardian mailing address (if different)
Emergency contact name *
Emergency contact phone *
Please list any medical, social, emotional, or learning conditions of the participant that are relevant for the instructor to know in order to keep the participant safe, as well as, design an appropriate program suited to their needs? *
Has the participant, or anyone else in their household been exposed to a person known to have COVID-19 within the last 14 days? *
Has the participant, or anyone else in their household, had the following symptoms in the last 10 days: fever, cough, shortness of breath, and/or diarrhea.
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How did you find out about Starshine?
Would you like to sign up for email updates from to learn about future Starshine opportunities?
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